HYGIENE, CLIENT SAFETY

 

PRINCIPLES OF PATIENT HYGIENE AND SAFETY

INTRODUCTION

Providing for a patient's hygiene is probably the most basic of all nursing care activities, but it is undoubtedly one of the most important. Not only is it a provision for the patient's physical needs; it also contributes immeasurably to the patient's feeling of emotional well-being.

 PURPOSE OF THE PATIENT'S DAILY BATH

a.                  Removal of bacteria from the skin.

b.                 Confinement in bed increases perspiration, and bacterial growth is stimulated by moisture.

c.                 Skin irritation from hospital bed linens may result in skin breakdown and subsequent infection. 

d.                 Relaxation effect on the patient.

e.                  Stimulation of blood circulation to the skin, respirations, and elimination.

f.                   Maintenance of joint mobility.

g.                 Improvement of the patient's self-image and emotional and mental well-being.

h.                 Providing the nurse with an opportunity for health teaching and assessment.

i.                    Providing the nurse with an opportunity to give the patient psychological support.

o                                            The process of building rapport may begin during the initial bath.

o                                            The bath aids in the development of the therapeutic nurse-patient relationship as the patient has the nurse's undivided attention.

 

PHYSICAL CONDITIONS WHICH ENCOURAGE SKIN BREAKDOWN IN A PATIENT WHO IS CONFINED TO BED

a.                  Immobility. Continuous pressure over any body part impairs circulation to that part and can cause breakdown and eventual ulcerations.

b.                 Incontinence. If the patient is unable to control the bladder or bowel functions, skin breakdown is likely to occur due to the presence of moisture and bacteria on the skin.

c.                 Emaciation. An emaciated patient may be prone to skin breakdown over bony prominence (heels, elbows, and coccyx).

d.                 Obesity. An obese patient may have many skin folds where perspiration and bacteria may contribute to skin breakdown.

e.                  Age-Related Skin Changes. An older person's skin is very thin and inelastic. The sweat and oil glands are less active. Thin, dry skin is more susceptible to pressure areas and skin breakdown.

f.                   Any Disease or Condition that Affects Circulation. Any disease or condition that affects circulation can encourage skin breakdown in a patient who is confined to bed.

 

 NURSING INTERVENTION TO PREVENT SKIN BREAKDOWN

a.                  The time of the patient's bath or back massage is the most logical time to thoroughly observe the patient's skin for pressure areas.

b.                 At the first sign of redness, the area should be washed with soap and water and rubbed with lotion; measures should then be taken to keep the patient off the reddened area.

c.                 Report any signs of pressure to the charge nurse.

d.                 Keep sheets under the patient clean, smooth, and tight to help eliminate skin irritation.

e.                  Ensure adequate nutrition and fluid intake, according to physician's orders.

f.                   Every effort should be made to keep urine and feces off the patient's skin, washing the skin with soap and water and keeping the buttocks and genital area dry (lotion or powder may be used depending upon the patient's skin type) when the patient is incontinent.

g.                 Obese patients may need assistance washing and drying areas under skin folds (groin, buttocks, under breasts, and so forth.)

h.                 For the patient with very dry skin, various bath oils may be added to the bath water.

o                                            Soap may be omitted because of its drying effect.

o                                            Lotions and oils may be used after the bath.

 TIMING OF PATIENT HYGIENE PROCEDURES

A patient's bath may be given at any time, according to the patient's needs, but certain routines are generally followed on a ward.

Morning Care.

1.                 The procedure followed in the morning affects the patient's comfort throughout the day.

2.                 Each morning before breakfast, the patient should be assisted to the bathroom, or a bedpan or urinal should be provided, according to the patient's activity level.

3.                 The patient is then given the opportunity to wash his/her hands and face and brush his/her teeth. The bed linen is straightened, and the overbed table is cleaned in preparation for the breakfast tray.

4.                 After breakfast, the patient has a complete bath (type is dependent upon the patient's condition and mobility), mouth care, a change of clothing, and a back massage.

5.                 Bed linens are changed; and the unit is cleaned and straightened to provide a comfortable and safe environment for the patient.

Evening Care.

1.                 The care the patient receives at the end of the day greatly influences the patient's level of relaxation and ability to sleep.

2.                 An opportunity is provided for elimination; the patient's hands and face are washed; the teeth are brushed; a back rub is given.

3.                 Bed linens are straightened; the patient's unit is straightened to ensure comfort and safety. It is important that there are no items, which the patient could slip on, or fall over, such as chairs or linens, on the floor.

 PROVIDING FOR SELECTED PATIENT NEEDS WHILE BATHING A PATIENT

Safety.

1.                 The bed may be in the high position during the patient's bed bath, but should be placed in the low position upon completion.

2.                 The side rails should be up after the patient's bath for the patient who is confined to the bed.

o                                            Side rails help to prevent falls for the elderly patient or the patient who is confused or has a decreased level of consciousness.

o                                            The legal aspect requires diligence on the part of nursing personnel.
 

3.                 The patient's call light should be within easy reach to prevent the need to reach for it and risk falling out of bed and to provide easy access in case of pain or distress.

4.                 Fire safety in the patient care area calls for the following rules:

o                                            No smoking in bed.

o                                            No smoking if oxygen is in use.
 

5.                 Always wash your hands before entering and upon leaving the patient's room.

Privacy.

1.                 Respect for the patient's privacy decreases the patient's emotional discomfort during personal care.

2.                 Keep the door to the patient's room closed.

3.                 Pull the curtains around the unit and drape the patient's body during care.

4.                 Allow the patient to complete as much personal care as possible; self-care is appropriate and provides additional privacy.

Comfort.

1.                 Ensure a comfortable temperature in the patient's room.

2.                 Close any windows and the door to the patient's room to prevent drafts and chilling.

3.                 Drape the patient appropriately during the bath.

4.                 For a bedside bath, maintain bath water between 110oF and 115oF; change the water as it cools and/or gets soapy.

SIGNIFICANT NURSING OBSERVATIONS DURING THE BATHING PROCEDURE

Physical Observations.

1.                 Observe the skin under good, natural light.

2.                 Any abnormal skin condition should be described as to its location, color, and size and how it feels to the patient.

3.                 The following skin observations should be checked upon admission and daily thereafter:

o                                            Cleanliness.

o                                            Odor. May be caused by sweat secreted by the sweat glands; by abnormal conditions, such as infection or kidney disease; or by bodily discharges (urine, feces) that need to be cleaned.

o                                            Texture. Smooth and elastic or dry and rough; nutritional deficiencies can influence skin texture.

o                                            Color. Reddened areas that could indicate pressure, cyanosis (bluish tinge) or jaundice (yellowish tinge).

o                                            Temperature. Hot skin could mean fever; cold skin could mean poor circulation.

o                                            Sensitivity. Pain, tenderness, itching, or burning.

o                                            Swelling (edema). Stretched or tight appearing; usually begins in the ankles or legs or any other dependent part; may be associated with injury.

o                                            Skin lesions. Rashes, growths, or breaks in the skin.
 

4.                 Observations may begin at the head (scalp) and proceed to the feet in a systematic manner.

Psychosocial Observations.

1.                 Problems in this area may be related to the patient's present problems.

2.                 The time of the patient's bath may be a good time to find out more about the patient's psychosocial needs.

3.                 Remember that the patient's nonverbal communication may tell you much about the way he/she is feeling.

Oral Care Supplies

BASIC PRINCIPLES OF MOUTH CARE

Purposes.

1.                 Provide oral care of the teeth, gums, and mouth.

2.                 Remove offensive odors and food debris.

3.                 Promote patient comfort and a feeling of well-being.

4.                 Preserve the integrity and hydration of the oral mucosa and lips.

5.                 Alleviate pain and discomfort, thereby enhancing oral intake.

General Guidelines.

1.                 Oral hygiene should be performed before breakfast, after each meal, and at bedtime.

2.                 Oral hygiene is especially important for patients receiving oxygen therapy, patients who have nasogastric tubes, and patients who are NPO. Their oral mucosa dries out much faster than normal due to their mouth-breathing.

3.                 You should provide for patient privacy during the procedure, as this is an extremely personal procedure for most patients.

4.                 Oral care for the unconscious patient should be performed at least every four hours.

5.                 Lipstick, chap stick, or vaseline may be applied to the lips to keep them from drying out.

Nursing Records. Nursing observations for the patient's mouth should be recorded in the clinical record, noting such factors as:

1.                 Bleeding.

2.                 Swelling of gums.

3.                 Unusual mouth odor.

4.                 Effect of brushing the teeth. Note if there is bleeding when you brush the patient's gums and teeth.

Conscious Patients with Dentures.

1.                 General considerations.

o                                            Many patients are sensitive or embarrassed about wearing dentures; therefore, the patient's privacy should be respected when the dentures are cleaned.

o                                            Dentures must be handled carefully; they are fragile and expensive, and the patient is handicapped without them.

o                                            If the dentures are left out of the mouth for any period of time, place them in a covered opaque container with the patient's name on the container.

o                                            Dentures must be kept in water to preserve their fit and general quality; the color may change if they become dry.

o                                            You may avoid breaking the dentures while cleaning them by holding them over a basin of water with a washcloth folded in the bottom.
 

2.                 Dentures are brushed in the same way as natural teeth; be sure to rinse them well.

3.                 The denture cup should be labeled with the patient's name and room number.

4.                 Never use hot water to rinse the dentures as it could warp them; use cool or lukewarm water.

5.                 The patient's gums and soft tissues should be cared for at least twice per day while the dentures are out of the mouth; a soft-bristled toothbrush, swab, or gauze-covered tongue blade dipped in mouthwash should be used to cleanse the gums, tongue, and soft tissues.

Patients With Mouth Complications. The following problems are common in patients receiving chemotherapy and radiation therapy:

1.                 Bleeding.

o                                            Observe the patient's mouth frequently for the amount of bleeding present and the specific areas.

o                                            Do not floss the patient's teeth; use a Water-pik®.

o                                            Brush the teeth and clean the mouth using one of the following methods:

§                                                                     1 Brush the teeth carefully with a very soft toothbrush.

§                                                                     2 Wrap a tongue blade with a gauze sponge saturated with a prescribed solution; carefully swab the teeth and mouth. Do not use lemon/glycerine swabs or commercial mouthwash because they contain alcohol, which causes burning.
 

2.                 Infection.

o                                            Observe the patient's mouth for appearance, integrity, and general condition.

o                                            Wear clean gloves during the procedure.

o                                            Obtain a culture, if ordered.

o                                            Do not floss the teeth if the mouth is irritated or painful.

o                                            Assist the patient with brushing the teeth and cleaning the mouth, using a soft toothbrush or a gauze-padded tongue blade.

o                                            Rinse the mouth with water and the prescribed solution, if ordered.
 

3.                 Ulcerations, to include stomatitis.

o                                            Basic procedure for the patient with an infection should be followed.

o                                            If the patient's mouth is extremely painful, rinsing the mouth with a local anesthetic, as prescribed by a physician, may be necessary.

o                                            Mouthwash and other solutions which contain alcohol should not be used for the patient with ulcerations as they are frequently very painful.

Unconscious Patients.

1.                 Oral care should be performed at least every four hours.

2.                 Oral suctioning may be required for the unconscious patient to prevent aspiration.

3.                 A soft toothbrush or gauze-padded tongue blade may be used to clean the teeth and mouth.

4.                 The patient should be positioned in the lateral position with the head turned toward the side to provide for drainage and to prevent aspiration.

                              

GUIDELINES FOR SHAVING A MALE PATIENT

If the patient is alert, question him about his shaving habits, and follow his routine as closely as possible.

1.                 Gather equipment and supplies.

o        Towels.

o        Washcloth.

o        Basin with hot water.

o        Shaving cream.

o        Razor.

o        Soap.

o        Aftershave lotion.

2.                 Wet the wash cloth, wring out any excess moisture, and apply it to the beard area (to soften the beard).

3.                 Apply shaving cream to the beard.

4.                 Shave the beard on the cheeks and upper lip in the direction that the hair grows.

5.                 Shave the beard on the neck against the direction of the hair growth.

6.                 Wash off any remaining shaving cream.

7.                 With clean water, finish washing the patient's face.

o        Always use an electric razor on patients with bleeding disorders to prevent uncontrollable bleeding from facial cuts.

o        Do not use plugged in electric razors on patients who are receiving oxygen therapy because of the danger of combustion; safety razors or rechargeable battery operated shavers are safe.

o        Consult with the charge nurse before shaving any patient who has had facial surgery or who may have hemophilia.

o        Patients who are combative, suicidal, or disoriented should have supervision and assistance while shaving.

PERINEAL CARE

Perineal care is often referred to as "pericare;" it consists of external irrigation of the vulva and perineum following voiding or defecation and is part of the routine A. M. and P. M. care. Patients may be able to perform their own perineal care or may need partial or total assistance from the nurse. Embarrassment on the part of the patient and the nurse can be effectively dealt with by ensuring patient privacy during the procedure and not totally exposing the patient's genital area.

Key points:

1.                 Ensure patient privacy.

2.                 Wipe from front to back (vagina toward rectum) on female patients to avoid contaminating the vagina or urethral meatus.

3.                 Do not use the same washcloth for any other portion of the patient's bath.

 BED PATIENT'S HAIR CARE

Principles for Shampooing the Bed Patient's Hair.

1.                 The supine position is preferred for weaker patients.

2.                 Patients with significant heart or lung disease will not tolerate being supine; they must be in a sitting position.

3.                 Hair care should be given regularly during illness, just as it would be normally.

Purposes of Hair Care.

1.                 Hair care improves the morale of the patient.

2.                 It stimulates the circulation of the scalp.

3.                 Shampooing removes bacteria, microorganisms, oils, and dirt that cling to the hair.

CLOSING.

Nothing points out loss of independence quite as much as an inability to perform personal hygiene unassisted. Your thoughtfulness and the professionalism you exhibit when assisting a patient with hygiene needs will foster that patient's feelings of independence, confidence, trust, and comfort.

SAFE ENVIRONMENT

Safety has a positive association with health promotion and illness prevention. A safe environment reduces the risk of accidents, subsequent alterations in health and lifestyle, and the cost of health care services. There are many factors in the environment that can threaten safety 

FACTORS AFFECTING SAFETY

Client safety is influenced by several factors such as age, lifestyle, sensory and perceptual alterations, mobility, and emotional state. 

Age

Risk for injury varies with chronological age and developmental stage. Health education about preventive measures can facilitate injury prevention for various age groups

As infants mature, their potential for injury increases. Infants, toddlers, and preschoolers are explorers of their environment. Most accidents involving these age groups are preventable with careful adult supervision to prevent falls from bed, burns, electrical hazards, choking on small objects, and drowning.

As school-age children explore their environment outside the home, their risk for injury increases. Prevention measures during this stage focus on not accepting candy, food, gifts, or rides from strangers; bicycle, skating, and swimming safety; and substance abuse.

Adolescents and young adults usually enjoy good physical health; however, their lifestyles put them at risk for injury. Since this age group spends much time away from home, collaborative educational efforts among parents, schools, and community health care providers need to focus on environmental safety. High-risk factors for injury and death are automobile accidents, substance abuse, violence, unwanted pregnancies, and sexually transmitted diseases.

Studies indicate that adolescents who initiate substance use in middle school and continue into high school are likely to become multisubstance users (tobacco, alcohol, and drugs). The progression from lighter to heavier use of illicit substances during adolescence leads to more serious multisubstance use careers.

Adult risk for injury is generally related to lifestyle, work practices, and behaviors. Prevention measures during this period emphasize nutrition, exercise, and occupational safety. High-risk factors for this age group include fatigue, anxiety, sleep pattern disturbances, caregiver role strain, and altered health maintenance.

The older adult is prone to falls, especially in the bathroom, bedroom, and kitchen, because of a loss of agility and visual acuity, predisposition to dizziness and syncope, and side effects of medications. Prevention measures for this age group emphasize slow position changes, good lighting, hand rails, and skidproof strips in the bathtub or shower and under rugs and carpets.

Each year, approximately one-third of people over the age of 65 who live at home fall; 15% of falls cause serious injuries, half of which are fractures that cost about $10 billion for hospital care (Winslow, 1998). Two Maryland hospitals worked together to implement a fall precaution program in their medical-surgical units and within 1 year lowered their fall rates from 9.3 falls per 1,000 client days to 7.3 per 1,000 client days (Sullivan & Badros, 1999). 

Lifestyle

Lifestyle practices can increase a person’s risk for injury and potential for disease. Individuals who operate machinery; experience stress, anxiety, and fatigue; use alcohol and drugs (prescription and nonprescription); and live in high-crime neighborhoods are at risk for injury. Risk-taking behaviors such as daredevil activities, driving vehicles at high speeds, and smoking are factors associated with accidents.

Sensory and Perceptual Alterations

Sensory functions are essential for accurate perception of environmental safety. If one of the senses is altered, then the other senses compensate to facilitate perception of the environment. For instance, a blind person usually will develop a keen sense of touch and hearing. Clients who have visual, hearing, taste, smell, communication, or touch perception impairments are at increased risk for injury. These clients are often not able to perceive a potential danger.

 Mobility

Clients who have impaired mobility are at increased risk for injury, especially falls. Mobility impairments may be a result of poor balance or coordination, muscle weakness, or paralysis. Immobility may also precipitate physiological and emotional complications such as decubitus and depression, respectively. 

Emotional State

Emotional states such as depression and anger affect a client’s perception of environmental hazards and degree of risk-taking behavior. These emotional states alter a client’s thinking patterns and reaction time. Usual safety precautions may be forgotten during periods of emotional stress. Self-confidence decreases when an elderly person falls; they tend to limit their activities because they fear falling again (Winslow, 1998). 

Types of Accidents

In the health care setting, accidents are categorized by their causative agent: client behaviors, therapeutic procedures, or equipment:

1. Client behavior accidents occur when the client’s behavior or actions precipitate the incident; for example, poisonings, burns, and self-inflicted cuts and bruises.

2. Therapeutic procedure accidents occur during the delivery of medical or nursing interventions; for example, medication errors, client falls during transfers,contamination of sterile instruments or wounds, and improper performance of nursing activities.

3. Equipment accidents result from the malfunction or improper use of medical equipment; for example, electrocution and fire.

National and institutional policies establish safety standards; for example, the risk for equipment accidents can be reduced by having the biomedical engineering department check the equipment inspection label prior to use. All accidents and incident reports must be fully documented according to institutional protocol.

 Potential Occupational Hazards

Nurses and other health care providers are at risk for injury in the workplace. Every day in the Unites States, 9,000 health care workers sustain a disabling injury on the job, according to the National Institute for Occupational Safety and Health (NIOSH) (Slattery, 1998). The Occupational Safety and Health Administration (OSHA), a division of the Department of Labor, has the power to enforce safety standards, and to cite and discipline agencies that are not in compliance with the standards (Bending, 2000).

Numerous hazards exist in today’s workplace such as latex allergy, blood-borne pathogens, work-related musculoskeletal disorders (MSDs), chemotherapeutic agents, environmental pollution, and violence. Findings from studies indicate that nurses who prepare or administer chemotherapeutic agents are exposed to occupational hazards from dermal absorption, ingestion, and inhalation from aerosolization of powder or liquid during reconstitution or from spillage (DelGaudio &Menonna-Quinn, 1998). According to the Bureau of Labor, almost two-thirds (64%) of nonfatal workplace assaults occur in nursing homes and hospitals (Slattery, 1998). The salient points regarding latex allergy and MSDs are discussed here; blood-borne pathogens are discussed later in this chapter. 

Latex Allergy

NIOSH (1997) issued an Alert entitled Preventing Allergic Reactions to Natural Rubber Latex in the Workplace. Latex products are manufactured from a milky fluid derived from the Brazilian rubber tree, Hevea brasiliensis. The allergic response is attributed to the proteins contained in the milky fluid and to the chemicals that are added during the processing and manufacture of commercial latex. There are three types of latex reactions: irritant contact dermatitis; allergic contact dermatitis, the most common type of reaction; and immediate hypersensitivity, a systemic reaction also called type 1 IgE–mediated reaction.

Since 1992, when OSHA issued regulations requiring health care workers to wear gloves and other protective devices such as surgical masks and goggles as a safeguard against blood-borne pathogens, health care workers were placed at risk for developing latex allergy. Commercial latex is in more than 20,000 medical products (Burt, 1999) such as blood pressure cuffs, stethoscopes, catheters, and wound drains, to name a few, as well as many household items. Reports indicate that 1–6% of the general population and about 8–12% of regularly exposed health care workers are sensitized to latex (NIOSH, 1997).

NIOSH (1997) recommends that employers and employees take a common sense approach based on current knowledge to protect workers from latex exposure and allergy in the workplace; refer to the accompanying display for NIOSH’s recommendations. NIOSH recommends that, if latex gloves are worn, they should be powder free and low allergen because these gloves are less likely than powdered ones to produce allergic responses (Gritter, 1998).
Work-Related Musculoskeletal Disorders

One-third of all occupational injuries reported by employers every year to the Bureau of Labor Statistics are work-related MSDs. Employers reported a total of 626,000 lost workdays in 1997, with these disorders costing workers’ compensation more than $15-$20 billion (OSHA, 2000).

According to OSHA (2000), it is estimated that only 28% of all workplaces in general industry have voluntarily implemented ergonomics programs. In response to these workplace hazards, OSHA has issued mandatory standards that require all employers to set up ergonomic programs to prevent work-related MSDs such as back injuries.

Work-related back pain affects 38% of nurses. The predominant cause of nurse back pain is lifting clients (Slattery, 1998). OSHA ergonomic standards state that a 51-pound stable object with handles is the heaviest amount that can be safely lifted. Health care providers are being challenged, in the midst of personnel cutbacks, to develop and implement safety policies that protect the provider and support OSHA’s ergonomic regulations.

The ergonomic standards require that all employers must provide workers the following information: common MSD hazards; signs and symptoms of MSDs, and the importance of reporting them early; how to report MSD signs and symptoms; and a summary of the requirement of the OSHA standard. The standards require the employer to ensure pay and benefits in the event that an employee needs to take time off or go on lighter duty because of a work-related MSD. 

HYGIENE

Hygiene is the science of health. Hygienic care promotes cleanliness, provides for comfort and relaxation, improves self-image, and promotes healthy skin. Client hygiene is an extension of providing client safety and protecting the client’s defense mechanisms. The health of the body’s first line of defense (skin and mucous membranes) is promoted by client hygiene. Nurses are responsible for assuring that the client’s hygienic needs are met. The type of hygienic care provided depends on the client’s ability, needs, and practices.

 Factors Influencing Hygienic Practice

Hygienic needs and practices are unique to each client; nurses should provide individualized care based on these needs and practices. Hygienic practices are influenced by several factors: body image, social and cultural practices, personal preferences, socioeconomic status, and knowledge.

 Body Image

Body image is the client’s subjective belief about his or her own physical appearance. Body image is associated with the client’s emotions, mood, attitude, and values. A client’s body image directly affects the type of personal hygiene practiced; this may change if the client’s body image is altered because of illness or surgical procedures. During this time, the nurse should help the client maintain hygienic practices in accordance with the client’s pre-illness level of hygiene and personal preferences. 

Social and Cultural Practices

Social and cultural practices also directly influence hygienic practices. Clients are socialized to their hygienic practices by family practices in early childhood. As a person ages, hygienic practices are influenced by maturational development and socialization with people outside of the family. For example, teenagers are usually concerned with peer acceptance and follow the latest trends in personal hygiene. In later adulthood, hygienic practices may be influenced by coworkers and social networks.

Cultural practices and beliefs are derived from family, religious, and personal values developed during maturation. Clients from diverse cultural backgrounds will have differing hygienic practices. For example, some cultures do not permit women to submerge their bodies in water during the time of menstruation because there is fear that the woman may drown. In North America, people typically bathe daily and use numerous deodorant products. In Europe, people do not bathe daily and seldom use deodorant products. Europeans do not consider the smell of human perspiration as offensive as do North Americans. Nurses should have a nonjudgmental attitude when assessing or providing hygienic care to clients from different social or cultural backgrounds.

 Personal Preferences

Personal preferences influence when bathing occurs, what products are used, and what type of bath is performed.

For example, some male clients may shave before bathing, while others prefer to wait until after the bath. Some clients prefer to bathe in the morning to facilitate waking, while others prefer to bathe before bedtime to encourage relaxation and sleep. Unless a client’s health is affected, the nurse should permit clients to practice their usual routine and use the hygienic products that they prefer. Individualized nursing care should incorporate the client’s personal hygiene preferences.

 Socioeconomic Status

A client’s hygienic practices may be influenced by socioeconomic status. Limited economic resources may affect the type, frequency, and extent of hygiene practiced. Assessment of socioeconomic status provides information about the availability of hygiene supplies. Some clients may not be able to afford deodorants, perfumes, soaps, shampoo, and toothpaste. The nurse can function as an advocate for the client by making referrals to community agencies that provide assistance to needy persons, for example, Catholic Charities or a local chapter of the American Association of Retired Persons (AARP). 

Knowledge

Knowledge level influences the client’s understanding about the relationship between hygiene and health. Thus, knowledge should influence a client’s hygienic practices. In addition to being knowledgeable, before clients perform basic hygiene, they must be motivated and believe that they are capable of self-care.

Frequently, an illness or surgical procedure results in deficient knowledge about basic hygienic practices. In these situations, the client may not know the correct procedures or types of hygiene that can be performed. The nurse is responsible for providing the necessary education about hygiene during an illness. Sometimes, the nurse may have to perform all hygienic practices for a client during an illness until the client is able to regain this ability. 

ASSESSMENT

The nursing process facilitates an understanding of the scope of challenges inherent in the nursing care of clients at risk for injury, infections, or a self-care deficit.

The assessment data should direct the prioritization of the client’s problem and accompanying nursing diagnoses.

Clients at risk for injury or infection require frequent reassessment of their status with appropriate changes in the plan of care and expected outcomes.

The assessment and physical examination data are correlated with the laboratory indicators to identify those clients who are at risk for problems relating to safety, infection, or hygiene. One of the assessment models should be used to provide structure to the assessment.

Appropriate risk appraisals may be incorporated into the nursing health history interview.

These core elements of assessment are discussed in relation to clients in ambulatory, institutional, and home settings. Refer to the accompanying display for a sample format for developing minimum safety standards applicable to all health care settings.

 

Health History

The nursing health history interview is the first part of assessment; it provides the client’s subjective specific health data. Key elements of relevant data regarding the client at risk for safety and infection are obtained in the health history. See Chapter 6 for a sample of a nursing health history tool.

The client is often asked to complete a health history questionnaire; however, depending on the client’s status, the nurse may have to perform an interview to obtain these data. If the client is unable to provide the subjective data, the nurse must designate on the questionnaire or in the nursing progress notes who provided the information.

During the nursing health history interview, assess the client’s general health perception and management status to determine how the client manages self-care.

This information will provide data regarding the client’s routine self-care and health promotion needs. Sample questions that relate specifically to habits that foster safe, healthy patterns of behavior are presented in the accompanying display. These questions are appropriate for home health and ambulatory care settings as well as inpatient settings.

Physical Examination

A complete health assessment includes a systematic physical examination, generally conducted from head to toes, in order to obtain objective data relative to the client’s health status and presenting problems.

When assessing the client to determine the level of risk for injury or infection and hygienic deficits, focus the physical examination on the following areas and signs:

 Level of consciousness: Use the Glasgow Coma Scale to evaluate this attribute.

 Range of motion or total immobilization of an extremity.

 Localized infection: Redness, swelling, warmth, tenderness, pain, and loss of movement in a specific body part.

 Systemic infection: Fever, with a corresponding increase in pulse and respirations; weakness; anorexia, with possible accompanying findings of nausea, vomiting, and diarrhea; enlarged and/or tender lymph nodes.

 Secretions or exudate of the skin or mucous membranes and detection of crackles, rhonchi, or wheezes in the lungs on auscultation.

The condition of the skin is a good indicator of a client’s general health status. Assessment of skin integrity provides data concerning a client’s nutritional and hydration status, continuity of intact skin, hygienic practices, and overall physical abilities. Similarly, a client with limited mobility is at risk for developing joint contractures, skin breakdown, and muscle atrophy.

Risk Factors

A comprehensive nursing assessment involves using specifically developed risk assessment tools and appraising the client’s environment to detect potential hazards. The client’s self-care abilities, used for determining the level of assistance needed in providing hygienic care, are appraised during the health history. The analysis of relevant risk factors alerts the nurse to actual or possible risks. Skin integrity is usually compromised when a person is placed on bed rest. A skin integrity risk appraisal such as the one shown in the accompanying display should be completed to assist with planning care.

Client in an Inpatient Setting

Inpatient clients should be assessed for fall and infection risk factors. The hospitalized or institutionalized client’s risk for falls is identified after compiling specific assessment data that are correlated with contributing factors. Each of these indicators carries a specific weight, as shown in the accompanying Fall Risk Appraisal, to determine the client’s risk. The inpatient client should be assessed for falls every shift or as designated by institutional policy. To minimize the chance of falls, make sure the client’s environment is safe: the bed is kept in a low position, side rails are up, personal belongings are in easy reach, and assistive devices (e.g., walker) are nearby.

Client in the Home

An injury risk appraisal will provide the nurse with assessment data to determine the client’s level of safety knowledge as previously discussed in the standard of care for safety. Injuries in the home are primarily the result of falls, fires, electrical malfunctions, suffocation, weapons, and household and medication poisonings. Home health nurses may use a safety risk appraisal; refer to the accompanying display.

The safety risk data assessed in the home environment direct the nurse in planning for the client and caregiver’s education. The home health nurse needs to prioritize these data when planning the client’s care. Assessment, teaching, and outcome evaluation of all safety hazards can take several home visits.

Diagnostic and Laboratory Data

Appraising the client’s risk for injury should also include an evaluation of laboratory findings relative to an abnormal blood profile (e.g., altered clotting factors, anemic conditions, or leukocytosis). Malnourished clients are at risk for injury.

The laboratory indicators for an infection are:

1. An elevated leukocyte (white blood cell [WBC]) and WBC differential:

 Neutrophils: Increased in acute, severe inflammation

 Lymphocytes: Increased in chronic bacterial and viral infections

 Monocytes: Increased in some protozoan and rickettsial infections and tuberculosis

 Eosinophils and basophils: Unaltered in an infectious process

2. An elevated erythrocyte sedimentation rate (ESR): Increased in the presence of inflammation

3. An elevated pH of involved body fluids (gastric, urine, or vaginal secretions): Indicates the presence of microorganisms

4. Positive cultures of involved body fluids (blood, sputum, urine, or other drainage): Indicates the growth of microorganisms 

NURSING DIAGNOSIS

After data collection and analysis, the nurse is able to formulate a nursing diagnosis. If Gordon’s Functional Health Patterns model is used to conduct the assessment, the nurse can use the classification of nursing diagnoses by functional health patterns that relate to safety, infection, and hygienic deficits; for example:

I. Health perception–health management pattern

 Risk for injury

 Risk for infection

II. Activity-exercise pattern

 Bathing/hygiene self-care deficit

 Dressing/grooming self-care deficit

 Toileting self-care deficit

 Risk for Injury

The primary nursing diagnosis Risk for Injury exists when the client is at risk of injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources (NANDA, 2001). Although this diagnostic label does not have defining characteristics as set forth by NANDA, it is categorized as having either internal or external potential hazards. An internal biochemical risk factor for a client with impaired vision would be stated as Risk for Injury related to sensory dysfunction. In contrast, a home health nurse’s assessment data that identify drugs on a nightstand with a toddler in the home as creating an external chemical risk factor for the toddler would be stated as Risk for Injury related to drugs (pharmaceutical agents).

NANDA (2001) has six defined subcategories of specific risk factors for this diagnostic labeling:

1. Risk for Suffocation: An accentuated risk of accidental suffocation

2. Risk for Poisoning: An accentuated risk of accidental exposure to, or ingestion of, drugs or dangerous products in doses sufficient to cause poisoning

3. Risk for Trauma: An accentuated risk of accidental tissue injury (e.g., wound, burn, fracture)

4. Risk for Aspiration: Risk for entry of gastrointestinal secretions, oropharyngeal secretions, or solids or fluids into the tracheobronchial passages

5. Risk for Disuse Syndrome: Risk for deterioration of body or body systems as the result of prescribed or unavoidable musculoskeletal inactivity

6. Latex Allergy Response: A response to natural latex rubber products

These six subcategories of nursing diagnoses provide the nurse with the opportunity to relate specific nursing interventions to the diagnosed problem. For example, the specific nursing diagnosis for the situation of a toddler in the home environment encountering medications on a nightstand would be Risk for Poisoningrelated to medicines not stored in locked cabinets and accessible to children. The level of risk would be increased if the medications on the client’s nightstand were in open containers or the closed containers failed to have childproof caps. The subcategory diagnosis provides specific nursing interventions directed at the level of risk for the toddler and the need for client teaching.

 Self-Care Deficits

A self-care deficit exists when the client is not able to perform one or more of the activities of daily living.

Other Nursing Diagnoses

Clients who are at risk for injury and infection or have a self-care deficit may have other problems. These associated physiological and psychological problems are discussed in detail in other chapters in this unit. The common nursing diagnoses that often accompany diagnostic labels for risk or self-care deficits are:

 Imbalanced Nutrition (specify less than body requirements or more than body requirements)

 Ineffective Protection

 Impaired Tissue Integrity

 Impaired Oral Mucous Membrane

 Impaired Skin Integrity

 Social Isolation

 Risk for Loneliness

 Ineffective Coping

 Impaired Physical Mobility

 Hopelessness

 Powerlessness

 Deficient Knowledge (specify)

 Acute Pain

 Anxiety

 Fear

This list is not all-inclusive but gives an indication of the number of related problems that need to be considered when planning care. 

OUTCOME IDENTIFICATION AND PLANNING

The primary nursing goal is to provide safe care through the identification of actual or potential hazards and the implementation of safety measures. The assessment data are reviewed with the client, and the nurse records the areas in which the client indicates a need for change and health teaching, for example, age-related exercise or maintaining a safe environment. These findings are incorporated into the plan of care, reflecting the individualized needs of each client.

During the planning phase, the nurse collaborates with the client and other health care providers to determine the goals, outcomes, and interventions and manipulates the external environment to reduce the risk of injury and infection. Identified outcomes provide direction for the nursing care that is implemented to reduce the risk of injury and infection.

Another critical element of the care plan is client/caregiver education related to the identification of potential hazards and health promotion practices.

The nursing care plan should include safety measures that educate clients about preventive actions and modification of an unsafe environment, for example, proper use of a call light or the side effects of medications.

Table 31-3 discusses the basic components of care planning and outcome measurements for clients at risk or with a self-care deficit. Sample statements of goals and expected outcomes are included in Table 31-3. The nursing interventions are statements taken from the Nursing Intervention Classification System. For each of these nursing interventions, there are specific actions taken by the nurse to individualize the care for each client. The nurse could use Gordon’s Functional Health Patterns to plan care. Gordon’s Functional Health Patterns that may be used for clients at risk or with a selfcare deficit are health perception–health management; activity-exercise pattern; and cognitive-perceptual pattern. Nursing actions are discussed in detail in the following section.

IMPLEMENTATION

Nursing care implemented for clients with alterations in health perception–health management or activity and exercise involves continual assessment of client health risks and prioritization of risk reduction nursing interventions, such as:

 Administration of prescribed medications

 Provision of balanced nutritional intake

 Promotion of adequate rest and exercise

 Decreasing the spread of infection

Implementation of safety measures may require an alteration in the physical environment as directed by the fall prevention protocol or Standard Precautions.

Nursing measures to counter common physical hazards that impair environmental safety are maintaining electric beds in the low position with side rails up and call light within easy reach and keeping the bedroom and bathroom uncluttered to prevent falls. Some states consider side rails a form of restraint. Nurses must be knowledgeable about statutory provisions relative to health care in their state. 

Raise Safety Awareness and Knowledge

Nurses in all settings must demonstrate an awareness of safety hazards and teach clients accordingly. Clients must be aware of and knowledgeable about safety precautions in order to prevent injuries. Clients may also need specific safety information on oxygen, intravenous equipment, use of heating devices, and automatic bed controls.

A Food and Drug Administration (FDA) safety alert addressed entrapment hazards with side rails on hospital beds. The FDA received 102 reports of head and body entrapment incidents that resulted in 68 deaths, 22 injuries, and 12 entrapments without injury that occurred in hospitals, long-term care facilities, and private homes.

Prevent Falls

Falls occur among clients who are weak, fatigued, uncoordinated, paralyzed, confused, or disoriented. The data obtained from the client’s fall risk appraisal will identify which clients require special nursing measures to prevent falls. The risk for falls can be reduced by:

 Good supervision

 Orienting clients to the environment and call system

 Providing ambulatory aids (wheelchairs or walkers)

 Placing personal belongings on tables near the bed

 Keeping hospital beds in lowest position with side rails up

 Using nonslip mats and rugs

 Illuminating the environment

Although falls do not necessarily constitute malpractice, they are a major reason why nurses are involved in lawsuits (Ignatavicius, 2000). Sullivan and Badros(1999) and Ignatavicius (2000) identify the need for registered nurses to assess patients’ risk of falls and implement evidence-based interventions. The concept ofevidencebased practice (EBP) refers to health care based on research findings, expert consensus, or both (Davis & Madigan, 1999). 

Apply Restraints

Restraints are protective devices used to limit the physical activity of a client or to immobilize a client or extremity. Restraints are used to protect the client, allow for treatment in a safe environment, and reduce the risk of injury to others.

The use of restraints has become very controversial because of client injuries from restraints. The Omnibus Budget Reconciliation Act (OBRA) of 1987 and the Health Care Financing Administration regulations of 1999 governing client’s rights are forcing a reexamination of how clients are cared for in acute and critical care settings (Bower & McCullough, 2000). In response to more individualized care regarding the use of restraints, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised their standards for restraint use with nonpsychiatric clients; see the accompanying display for JCAHO-revised standards.

Nurses must document, according to the institutional protocol, the application and care of the client in restraints (see the accompanying display).

Restraints used to either limit physical activity or immobilize a client can be physical or chemical.

Physical restraints reduce the client’s movement through the application of a device. Most states require a physician’s order for the application of physical restraints. Chemical restraints are medications used to control the client’s behavior. Commonly used chemical restraints are anxiolytics and sedatives.

Ensure Adequate Lighting

Adequate lighting assists in the visualization of environmental hazards. Rooms should be adequately lighted so that the client can safely perform ADL and health care providers can perform procedures. Lighting can be supplemented by lamps and nightlights. Lighting can also assist in protecting the home against crime. 

Remove Obstacles

Obstacles in heavily traveled areas of health care facilities or homes are a risk to the client’s safety. Older adults or persons who are unfamiliar with the environment are at greatest risk of injury from obstacles. The risk that obstacles pose can be reduced by keeping hallways clear, removing excess furniture from heavily traveled areas, removing all electrical cords or taping cords securely to the floor, removing throw rugs, applying nonslip pads to rugs, cleaning up spills immediately, and removing objects that could fall from the tops of appliances.

 Reduce Bathroom Hazards

Bathrooms pose a threat to the client in the home because of the presence of water and storage of medication.

Common bathroom accidents are falls, scalds or burns, and poisonings. Bathroom accidents can be reduced by the use of grab bars near the tub, shower, and toilet; nonslip mats in the tub and shower; and a secured bathroom rug near the tub or shower. Other safety measures include checking the temperature of the water before entering tub or shower; checking the thermostat setting on the water heater; and storing medications in a locked cabinet, out of reach of children or disoriented or confused adults. 

Prevent Fire

Fire is a potential danger to all people in an institutional or home environment. Immobilized or incapacitated clients are at increased risk during a fire. Common causes of fire are smoking in bed, discarding cigarette butts in trash cans, and faulty electrical equipment. Fire occurs with the interaction of three elements: sufficient heat to ignite the fire, combustible material, and oxygen to support the fire.

Nursing goals are fire prevention and protection of clients during a fire. Nursing interventions aimed at preventing or reducing the risk of fire include:

 Clearly marking fire exits

 Knowing locations of fire extinguishers and their operation

 Practicing fire evacuation procedures

 Posting emergency phone numbers by all telephones

 Keeping open spaces and hallways clear of clutter

 Checking electrical cords and outlets for exposed or damaged wires

 Reporting identified electrical hazards

 Educating clients about fire hazards

In the event of a fire, follow institutional policy and procedures for fire containment and evacuation.

Nursing interventions during a fire are directed at protecting the client from injury and containing the fire. Nurses should be familiar with the location of fire alarm pull boxes. If a fire occurs, the nurse should utilize the nearest fire box for notification and move clients to safety.

Nurses should be familiar with the use of fire extinguishers and their locations. The fire extinguisher should be directed toward the base of the fire. The four types of fire extinguishers used are water, carbon dioxide, regular dry chemical, and multipurpose dry chemical. Each type of fire extinguisher is used for a specific class of fire, as discussed in Table 31-5.

Ensure Safe Operation of Electrical Equipment

Clients have contact with a variety of electrical equipment in the hospital environment, such as bed controls and intravenous and patient-controlled analgesia (PCA) pumps. All electrical equipment should have a threepronged electrical plug that is grounded. A grounded plug transmits any stray electrical current from equipment to the ground. To protect the client from electrical injury, the nurse should read the warning labels on all equipment, use only grounded electrical equipment, check for frayed electrical cords, avoid overloading circuits, and report any shocks received from equipment to the biomedical department (see Figure 31-9).If a client receives an electrical shock, the nurse should turn off or remove the electric source before touching the client. Then, the client’s pulse should bechecked. If the client has no pulse, CPR should be initiated.

If the client has a pulse, the nurse should assess vital signs, mental status, and skin integrity for burns. A physician should be notified of the event. The nurse should note points of entry and exit of electrical current to assess for potential complications.

 Reduce Exposure to Radiation

Clients are exposed to radiation during diagnostic testing and therapeutic interventions. Injury can occur from radiation if there is overexposure or exposure to untargeted tissues. Exposure to untargeted tissues can occur with radiation implants that become dislodged.

General principles of radiation exposure and protection are based on time, distance, and shielding. Protection from radiation therapy includes:

 Minimizing time in contact with radiation source (implants or client)

 Maximizing distance from radiation source (implants or client)

 Using appropriate radiation shields

 Monitoring radiation exposure with a film badge

 Labeling all potentially radioactive material

 Never touching dislodged implants or body fluids of client

Both the client and the nurse are at risk for radiation injury. The client’s risk for injury can be reduced by educating the client about radiation treatment and necessary precautions, placing the client in a private room, and providing a lead apron when necessary to protect nontargeted body tissues. The nurse’s risk for injury can be reduced by observing all radioactive labels, wearing gloves when handling radioactive body discharges, washing hands, wearing lead aprons, disposing of radioactive substances in special containers, reducing time of client contact, and wearing badges that measure the amount of radiation exposure. 

Prevent Poisoning

A poison is any substance that causes an alteration in the client’s health, such as injury or death, when inhaled, injected, ingested, or absorbed by the body. Antidotes and treatments are available for some but not all types of poisonings. Direct and indirect causes of poisonings are:

 Inadequate supervision of children

 Ingestion of household plants

 Improper storage of toxic substances

 Insect or snake bites

 Accidental ingestion of a toxic substance or medication overdose

The poison control center should be notified when poisoning is suspected. The person reporting the poisoning should be prepared to state the amount and type of poison ingested, inhaled, or injected, client’s age, and symptoms. Clients who have ingested poison should be turned on their side to prevent aspiration while awaiting further treatment. Client education about safety measures can prevent some accidental poisonings.

The following Client Teaching Checklist provides some safety measures to prevent accidental poisoning. Keep syrup of ipecac available at all times.

Reduce Noise Pollution

Noise pollution, a situation that results when the noise level becomes uncomfortable for the client or staff, frequently occurs in the health care setting as a result of visitor traffic, medical equipment, and personnel. It can result in an unorganized environment, hearing loss, and sensory overload. Sensory overload is an increased perception of the intensity of auditory and visual stimuli.

Sensory overload can alter a client’s recovery by increasing anxiety, paranoia, hallucinations, and depression.

Safety measures include maintaining a quiet environment, traffic control, and providing earplugs.

 Provide for Client Bathing Needs

Bathing of clients is an essential component of nursing care. Whether the nurse performs the bath or delegates the activity to another health care provider, the nurse retains the responsibility for assuring that the hygienic needs of the client are met. The type of bath provided will depend on the purpose of the bath and the client’s self-care ability. The two general categories of baths are cleaning and therapeutic.

Cleaning Baths

Cleaning baths are provided as routine client care. The purpose of a cleaning bath is personal hygiene. The five types of cleaning baths are shower, tub, self-help, or assisted bed bath, complete bed bath, and partial bath.

Shower

Most ambulatory clients are capable of taking a shower. Clients with limited physical ability can be accommodated by placing a waterproof chair in the shower (Figure 31-28). The nurse provides minimal assistance with a shower. The Nursing Checklist discusses guidelines for helping clients with tub or shower baths.

Tub Bath

Clients frequently prefer and enjoy tub baths. A tub bath permits washing and rinsing in the tub. Tub baths can also be therapeutic. Clients with limited physical ability should be assisted with entering and exiting the tub.

Self-Help Bath

A self-help, or assisted, bed bath is used to provide hygienic care for clients who are confined to bed. In the self-help (assisted) bed bath, the nurse prepares bath equipment but provides minimal assistance. This assistance is usually limited to washing difficult-to-reach body areas such as the feet and back.

Complete Bed Bath

A complete bed bath is provided to dependent clients confined to bed. The nurse washes the client’s entire body during a complete bed bath. Procedure 31-9 outlines the actions involved in giving a complete bed bath.
Partial Bath

A partial (or abbreviated) bath consists of cleaning only body areas that would cause discomfort or odor if not washed thoroughly. These areas are the face,axillae, hands, and perineal area. The nurse or client may perform a partial bath depending on the client’s self-care ability. Partial baths may be performed with the client lying in bed or standing at the sink.

 Therapeutic Bath

Therapeutic baths require a physician’s order stating the type of bath, temperature of water, body surface to be treated, and the type of medicated solutions to use. A therapeutic bath is usually performed in a tub and lasts about 20 to 31 minutes. Therapeutic baths are classified as hot or warm water, cool or tepid water, soak,sitz, oatmeal or Aveeno, cornstarch, or sodium bicarbonate, depending on the prescribed type of bath.

Hot- or warm-water tub baths are used to reduce muscle spasms, soreness, and tension. Hot- or warm-water baths, however, have the potential for causing skin burns. Cool or tepid baths are used to relieve tension or lower body temperature. The nurse needs to prevent chilling and rapid temperature fluctuations during a cool or tepid bath.

A soak can include the entire body or be limited to only one body part. A soak consists of applying water, with or without a medicated solution, to reduce pain, swelling, or irritation or to soften or remove dead tissue.

Sitz baths cleanse and reduce inflammation in the perineal and anal areas. Sitz baths are commonly used for hemorrhoids or anal fissures and after perineal or rectal surgery. Skin irritations can be soothed with oatmeal or Aveeno, cornstarch, or sodium bicarbonate baths. 

Provide Clean Bed Linen

After a bath, clean linens are placed on the bed to promote comfort. If the client is able to get out of the bed, assist the client to a chair and proceed with making the bed. Procedure 31-10 describes the steps involved with making an unoccupied bed. After surgery, the client should be returned to a clean bed with the linens folded to the foot of the bed to promote easy client transfer.

If the client is unable to get out of the bed, refer to Procedure 31-11 for a description of the steps involved in making an occupied bed. Assistance will be needed if the client is in traction or cannot be turned. Care must be taken to avoid disturbing the traction weights. If the client cannot be turned, change the linen from head to toe. Place a waterproof draw sheet on the beds of clients who are incontinent or have profuse drainage.

Provide Skin Care

The skin functions as a protective barrier between the internal and external environments. In addition, the skin functions to regulate body temperature, secrete sebum, excrete sweat, transmit sensations, and facilitate absorption of vitamin D.

Skin care provides cleansing and conditioning to promote the optimal functioning of the skin. It consists of providing adequate nutrition, baths, perineal care, and back rubs. Excessive or abrasive skin care can damage skin and result in loss of function. Performing skin care provides an excellent opportunity for the nurse to assess skin integrity.

 Perineal Care

Perineal care is cleansing of the external genitalia, perineum, and surrounding area. Perineal care is also referred to as “peri-care” or “perineal-genital” care. The purposes of perineal care are to prevent or eliminate infection and odor, promote healing, remove secretions, and provide comfort. Perineal care can be provided alone or as part of the bed bath.

Perineal care may be an embarrassing procedure for both the client and the nurse, especially if the client is of the opposite sex. Clients who are embarrassed may elect to perform their own perineal care.

In this situation, the nurse should provide the client with warm water, moistened washcloth, soap, a dry towel, and privacy. If the client is unable to performperineal care, the nurse is responsible for providing this care in a professional and private manner.

Offer Back Rubs

Back rubs and massages stimulate the client’s circulation, relax muscles, and relieve muscle tension as well as provide the nurse with an opportunity for skin assessment.

Emollient creams and lotions are used to facilitate the rubbing and lubrication of the skin during a back rub or massage.

The client is positioned prone or side-lying. Nurses create friction and pressure by rubbing their hands on the client’s skin. The friction creates heat, which dilates the peripheral circulation and increases the blood supply to the skin. The pressure provides manual stimulation to muscle fibers, which relaxes the muscles.

Prior to performing a back rub or massage, the nurse must assess for contraindications. Caution should be exercised when massaging limbs. Massaging limbs, especially the lower limbs, could dislodge a thrombus (blood clot), creating an embolus (circulating blood clot). Bony prominences should be massaged lightly to avoid damaging underlying tissue.

Provide Foot and Nail Care

Proper foot and nail care are essential for ambulation and standing. Foot and nail care are often ignored until problems exist. Common problems with feet and nails may be a direct result of abuse and neglect, such as from inadequate foot and nail hygiene, fingernail and cuticle biting, incorrect nail trimming, poorly fitted shoes, and exposure to harsh chemicals. These problems result in alterations of skin integrity with the potential for infection.

The first signs of foot and nail problems are usually pain or tenderness. These symptoms affect a client’s posture and may result in limping with subsequent strain on certain muscle groups. Clients with illnesses such as diabetes mellitus need special foot and nail care. Clients with diabetes mellitus experience alterations in circulation that predispose them to foot problems.

The purposes of foot and nail care are to prevent infection and soft tissue trauma from ingrown or jagged nails and to eliminate odor. Hygienic care of feet and nails consists of regular trimming of nails; cleaning under nails; cleaning, rinsing, and drying feet and nails; and wearing properly fitted shoes. The following Nursing Checklist discusses the specific interventions that should be taken in providing foot and nail care.

Soaking of nails assists with their cleaning if nails are dirty or thickened. An orangewood stick is used to clean under nails since a metal instrument can roughen the nail and cause it to harbor dirt. The safest instrument to trim nails is the nail clipper; however, some clients feel that cutting the nails makes them brittle. If the client chooses not to cut the nails, the nails should be filed straight across. Special attention should be given to drying the areas between the toes.

An emollient, such as cold cream, helps to keep nails and cuticles soft.

Callused areas should never be cut. Repeated soaking usually facilitates the removal of calluses. Lotion should be applied to the foot to maintain moisture and soften callused areas. If the client’s feet maintain excessive moisture (sweat), water-absorbent powder should be applied between the toes.

The client should wear clean, properly fitted shoes.

The fit should not be extremely tight but should be snug enough to provide support to the foot. An arch support should be in each shoe. Shoe size should be large enough so that the shoe is one-half inch longer than the longest toe. Common foot problems can often be alleviated by assessing footwear and providing proper education on footwear and foot and nail care.

Provide Oral Care

The oral cavity functions in mastication, secretion of mucus to moisten and lubricate the digestive system, secretion of digestive enzymes, and absorption of essential nutrients. Common problems occurring in the oral cavity are:

 Bad breath (halitosis)

 Dental caries (cavities)

 Plaque

 Periodontal disease (pyorrhea)

 Inflammation of the gums (gingivitis)

 Inflammation of the oral mucosa (stomatitis)

Poor oral hygiene and loss of teeth may affect a client’s social interaction and body image as well as nutritional intake. Daily oral care is essential to maintain the integrity of the mucous membranes, teeth, gums, and lips. Through preventive measures, the oral cavity and teeth can be preserved. Preventive oral care consists of fluoride rinsing, flossing, and brushing.

Fluoride

Researchers have determined that fluoride can prevent dental caries. This finding has led to the fluoridation of water supplies in many communities. Fluoride is a common component of mouthwashes and toothpastes.

However, persons with excessive dryness or irritated mucous membranes should avoid commercial mouthwashes because of the alcohol content, which causes drying of mucous membranes.

Fluoride supplements are available without a prescription.

Infants can be given fluoride drops as early as 2 weeks of age to prevent dental caries. Nurses should educate clients about fluoride being an excellent preventive measure against dental caries.

However, excessive fluoride usage can affect the color of tooth enamel. To prevent discoloration of the tooth enamel, fluoride should be administered with a dropper directed toward the back of the throat.

 Flossing

Flossing should be performed daily in conjunction with brushing of teeth. Flossing prevents the formation of plaque, removes plaque between the teeth, and removes food debris. Dental caries and periodontal disease can be prevented by regular flossing. Flossing is best performed after toothpaste is applied to the teeth but before brushing . This order permits the fluoride in the toothpaste to have direct contact with the tooth surfaces, thus preventing dental caries.

Flossing can also be performed after brushing, but brushing first does not maximize the fluoride’s contact with the tooth surfaces.

 Brushing

Brushing of teeth should follow flossing. Teeth should be brushed after each meal. Brushing should be performed using a dentifrice (toothpaste) that contains fluoride to aid in preventing dental caries. An effective homemade dentifrice is the combination of two parts salt with one part baking soda. Brushing removes plaque and food debris and promotes blood circulation of the gums.

Dentures should be brushed using the same brushing motion as that used for brushing teeth.

Oral Care for the Unconscious Client

Oral care for the unconscious client maintains a clean oral cavity and intact mucous membranes. Special care should be exercised when performing oral care to unconscious clients to prevent client aspiration or injury to the nurse (client biting because of gag reflex). The accompanying Nursing Checklist provides essential safety guidelines for providing oral care to unconscious clients.

Provide Hair Care

Hair affects a client’s personal appearance and body image. Hair functions to maintain the body temperature and as a receptor for the sense of touch.

Assessment of hair texture, growth, and distribution provides information on a client’s general health status.

Common hair problems are dandruff, hair loss, tangled or matted hair, and infestations such as pediculosis and lice. Hair problems can be reduced by daily hair care, which helps to promote hair growth, prevent hair loss, prevent infections or infestations, promote circulation of the scalp, evenly distribute oils along hair shafts, and maintain the client’s physical appearance. Hair care consists of brushing and combing, shampooing, shaving, and mustache and beard care.

 Brushing and Combing

Hair should be brushed or combed daily according to the client’s preferred hairstyle. Brushing and combing stimulate circulation to the scalp, distribute oils along hair shafts, and arrange the placement of hair. A clean brush or comb should be used. Hair should be brushed from the scalp toward the hair ends. Sensitive scalps should be brushed or combed gently. Wetting the hair with water before brushing or combing can prevent damage to the hair and painful pulling of the scalp.

Clients who are immobilized may have tangled or matted hair. Care should be taken to prevent pain when combing tangled or matted hair by holding the tangled hair near the scalp while combing. If the client permits, the hair can be braided to avoid tangling or matting, but braiding the hair tightly should be avoided since tight braids may cause pain and hair loss. A nurse must receive written informed consent to cut a client’s hair.

 Shampooing

When soiled, hair should be shampooed according to the client’s usual routine. The purposes of shampooing are to stimulate scalp circulation, remove soil from hair, and facilitate brushing and combing. Hair can be shampooed in the tub, in the shower, at the sink, or in the bed depending on the client’s abilities and preferences.

Clients confined to bed can have their hair shampooed with water or with shampoos that do not require water (see Nursing Checklist: Shampooing Hair in Bed). Hair is shampooed by thoroughly wetting all hair, applying about a teaspoon of shampoo, lathering shampoo, and gently massaging the scalp with the pads of the fingertips. Hair should be rinsed thoroughly after shampooing. Hair should be dried with an absorbent towel, then brushed or combed in the preferred hairstyle.

Shaving

Shaving is the removal of hair from the skin surface.

Males often shave to remove facial hair, and women may shave to remove leg and/or axillary hair. Operative procedures may also require skin preparation that requires shaving of an area of the body.

Shaving may be performed before, during, or after the bath. Care should be used to avoid cutting the skin. Prior to shaving, the area should be washed with soap and warm water to soften the hair. A warm washcloth may be placed over the area for a few minutes to assist with softening the hair. A shaving cream or mild soap is applied to the area to ease hair removal. To shave, the skin should be pulled taut. The razor is held at a 45 degree angle and moved over the skin in short, firm strokes in the direction of hair growth. After the skin is shaved, it should be washed, rinsed, and patted dry.

Mustache and Beard Care

Mustaches and beards require daily care. Mustache and beard care consists of keeping the hair clean, trimmed, and combed. Mustaches and beards can be washed with soap or a shampoo. Frequently, mustaches and beards require only gentle wiping with a moist washcloth. A mustache or beard should never be shaved by the nurse without written informed consent. 

Provide Eye, Ear, and Nose Care

Eye, ear, and nose care should be included in routine hygienic care.

 Eyes

Eyes are continually cleansed by the production of tears and movement of eyelids over the eyes. Eyelids should be washed daily with a warm washcloth from the inner to outer canthus. Eyelashes function to prevent foreign material from entering the eyes and conjunctival sacs. Eyelashes and eyebrows should be washed as necessary.

A client’s artificial eye (prosthetic) may require daily cleaning, which requires that the eye be removed from the eye socket and washed (see Procedure 31-14). Some artificial eyes are permanently implanted.

Comatose clients have special eye care needs since they lack a blink reflex. These clients require frequent instillations of lubricants or eyedrops to prevent corneal abrasions. The accompanying Nursing Checklist describes eye care for the comatose client.

Contact Lenses

The nursing history should indicate if the client wears contact lenses, and the routine care and level of assistance should be recorded on the client’s care plan.

Clients who can insert, remove, and manage the care of their lenses will require minimal assistance from the nurse. If the client is unable to assist with lens care and also has corrective eyeglasses, suggest to the client that he or she wear the eyeglasses during hospitalization.

There are two types of contact lenses: hard and soft. Each type requires different cleaning and care (see Procedure 31-14). During emergency situations, the nurse should remove the lenses and place them in the appropriate solution.

 Ears

Hearing can be affected by foreign material or wax in the external ear canal. Cleaning of the ears involves cleaning of the external ear canal and auricles. Objects should not be inserted into the ear canal. Excess wax or foreign material should be removed by gently washing the external ear and auricles with a warm washcloth while pulling the ear downward in the adult client. Irrigation of the ear may be necessary to remove dried wax. The physician should be notified prior to irrigation of the ear.

Hearing Aids

Hearing aids amplify sound. The health history should indicate if the client is wearing a hearing aid and the plan of care should discuss the cleaning schedule of this aid. Clients with hearing aids should clean the ear mold regularly to ensure proper functioning. There are four types of hearing aids:

 Body-worn

 Eyeglass

 Behind the ear

 In the ear

Some hearing aids have a telephone switch that can be turned on and off.

If the hearing aid is not functioning properly, check the on-off switch and volume control, battery (replace as necessary), plastic tubing for cracks and loose connections, and telephone switch, which should be in the off position unless the client is using the phone. Hearing aids should be handled carefully since dropping or bumping the hearing aid can damage its delicate mechanisms. When not in use, the hearing aid should be stored in a container because dust and dirt can damage the mechanism.

When communicating with a client who has a hearing aid, you should address the client by name and then wait for the client to face you before speaking further. Always face the client and speak in a slow, natural voice. Shouting causes distortion of sound and usually makes the client feel uncomfortable.

 Nose

The nose provides the sense of smell, prevents entrance of foreign material into the respiratory tract, humidifies inhaled air, and facilitates breathing. Excessive or dried secretions may impair nasal function. Excessive nasal secretions are removed by inserting a cotton-tipped applicator moistened with water or saline into the nostrils.

The applicator should not be inserted beyond the cotton tip. Infants may have excessive nasal secretions removed by a suction bulb. Clients with a nasogastrictube should receive meticulous skin care to the nose area to prevent skin breakdown.

 EVALUATION

Evaluation is based on the achievement of goals and client expected outcomes, regardless of the setting.

Clients with alterations in health perception–health management pattern or activity-exercise pattern are at risk for injury, infection, and self-care deficits. Keeping the client free from injury and infection requires frequent reassessment, through the use of risk appraisals, with timely adjustments made in the plan of care in order for nursing interventions to be effective.

It is imperative that the client not only be free of injury during hospitalization but also develop a true awareness of the internal and external factors that increase the risk for injury. Achievement of this outcome measure is directly related to the behaviors the client observes while in the hospital and through client teaching. Modification of a home to a safe environment is evidence for the home health nurse that learning has taken place.

Adherence to barrier precautions is critical in preventing the spread of infectious agents, especially nosocomial infections to clients, self, and other health care workers. The nurse needs to correlate the client’s diagnostic laboratory results and temperature in evaluating the expected outcome of remaining free of signs and symptoms of infection. If the nurse is caring for a client with an infection, the evalaution should indicate the stage of the inflammatory process (refer to Table 31-1).

The therapeutic value of hygiene is maximized when the client can particiapte and is kept free from infection and alterations in skin integrity. Evaluation should identify the client’s level of functioning in self-care activities.

At the time of discharge from the hospital, appropriate referrals should be made to home health care agencies to assist the client in achieving optimum functioning levels for safety and hygienic practices. Clients at risk for infection should have follow-up visits by the home health nurse to measure the effectiveness of client teaching and resources in the home to prevent the transmission of infections.

KEY CONCEPTS

 Factors influencing client safety are age, lifestyle, sensory and perceptual alterations, mobility, and emotional state.

 Types of accidents that can occur in the health care setting are client behavior, therapeutic procedure, and equipment accidents.

 Assessment of a safe environment consists of performing an injury risk appraisal.

 Nurses can help clients in maintaining a safe environment by resolving or alleviating hazards related to falls, lighting, obstacles, bathroom hazards, fire, electricity, radiation, poisoning, and noise pollution.

 The chain of infection involves a biological agent, a reservoir of the agent, a portal of exit, a mode of transmission, a portal of entry of the agent into the host, and a susceptible host.

 Medical and surgical asepsis prevent the transfer of microorganisms by implementation of practices that reduce the number, growth, or spread of microorganisms from an object or area.

 The new guidelines from the CDC require that transmission-based precautions be used for specific syndromes that are highly suspicious for infections until a diagnosis is confirmed.

 Hygienic practices are influenced by body image, social and cultural practices, personal preference, socioeconomic status, and knowledge.

 Basic hygienic practices include bathing, skin care, perineal care, back rubs, foot and nail care, oral care, hair care, and eye, ear, and nose care.